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Hospital Access Management recently spoke with Jack Resneck, Jr., MD, chair-elect of the American Medical Association (AMA) and a practicing dermatologist, about prior authorization reform:
“It really did confirm what each of us on the front lines taking care of patients is experiencing. It’s just as bad as each one of us feels that it is in our daily practice. The problem is real, and it continues to get worse.”
“I hear from my own patients every day about their frustration with the authorization process. I’m writing a prescription for them that I think will be helpful. Whenever possible, I try to be a good steward of resources and use affordable options. Then, to their surprise and my surprise, often times the patient will show up at the pharmacy and find that the medication has a prior authorization, or has a much larger copay than anticipated, or isn’t covered at all. This is frustrating for both patients and doctors.
“It’s very hard for me as a physician at the point of care, writing a prescription, to know: Is this one going to require a prior auth? It used to be much more predictable. For very expensive or new medications, you could anticipate they were going to be needed, and you could get the authorization in advance. But nowadays, I can be writing for a generic topical cream that has been around for 30 years, and when the patient shows up at the pharmacy, we find out it needs a prior auth.
“The system to get medications to patients, and the system to get prior authorization, has gotten more opaque for everybody. Not only do you have the health plan involved, you have pharmacy benefits managers that are sometimes in the middle. It’s tough for all of us to know in any given case where the problem lies. Is it the drug manufacturer, or the pharmacy benefit manager, or the health plan? The AMA has tried to draw attention to the lack of transparency around how drug pricing and prior authorization processes work.
“Physicians are the closest point of access, so we hear a lot of that frustration. When a patient finds out the drug I prescribed isn’t covered without a prior auth, we usually get it submitted that same day. I may not hear from the health plan for a few days, and when I do hear back, it’s just the first go around. You seem to almost get an automatic rejection. Then, you have to do another level of appeal, which either means more paperwork or spending a lot of time on hold.
“Sometimes we hear, ‘We will not cover that, but here are some alternatives.’ And those are coming from somebody who clearly doesn’t know the patient’s condition. Sometimes, the things they suggest are way out of bounds and inappropriate for what patients have. And while we are back and forthing with the health plan, the patient is waiting.
“Physicians spend all that time fighting these battles because they want patients to get access to the care that they need. But all the time I spend doing that is time that I’m not spending with another patient. At the end of the day, that affects access to care and my availability to everybody else.
“Sometimes, we get the prior authorization for a drug, and the patient’s condition is getting better because they finally found something that works for them. But months later, either they change health plans, or something about the health plan’s formulary changes. Then, you have to repeat the prior auth process for the same drug and the same patient. It’s especially scary for the patient when their condition is getting better. Now, the patient can’t maintain continuity when they’ve finally found something that works.”
“What these two situations have in common is that at the end of the day, they create access to care frustrations for patients. The frustrations are a little bit different. In the first go around with managed care, a lot more attention was directed on access to individual physicians and referrals.
“This prior authorization quagmire that we find ourselves in now is driven partly by the cost of pharmaceuticals. In the last decade, there is no doubt we’ve seen increased costs. It’s not just because there are exciting new treatments out there that we expect to be expensive. We are seeing prices increase even on generics and branded drugs that have been out for several years and don’t have recent R&D involved with them. In some cases, the health plans have increased these prior auth requirements in response to these increasing costs. My guess is that’s been driving some of this.”
“We assembled a group that included pharmacists, hospitals, doctors, and health plans to talk about what next steps will be. We actually had some health plans in the room that signed on to an agreement to try to make progress in this area.
“I think we are going to see a continued variation in health plans. Some will come to the table to work collaboratively earlier than others. Those conversations are ongoing.
“There is a lot of low-value work that is affecting our side and the health plan side as well. There are certain medications and tests, where the overwhelming majority eventually get approved, after a lot of work on both sides. We feel those are a good place to start in terms of reducing the numbers of drugs and tests that are subjected to prior auth.
“Obviously, there will continue to be some very expensive and new things that will continue to be on the list. Even if a high percentage are approved, from the health plan standpoint there may be some savings that are motivating them to keep them on the list. The reality is that physicians and payers are going to need to work together on multiple issues related to affordability and access and quality of care. Reducing this burden would help that collaborative relationship, and help us work together on other things.
“We also think that if individual clinicians have demonstrated a pattern of using evidence-based medicine and having all of their prior authorizations approved over a period of time, that healthcare plans should actually exempt them from many of the requirements. You can imagine a sort of gold-carding process where physicians who demonstrated good prescribing would therefore have lower hurdles.
“One thing we are working with health plans on is being able to see, at the time that we prescribe, what things are covered and not. You’d think that would be pretty straightforward with computers these days. But you’d be surprised at how little that information they share with us at the time we’re prescribing as to what’s covered — or if it requires a prior auth, what are the requirements, so I know if it’s something they will agree to approve or not. If that’s something that showed up right in my EHR when I’m prescribing, that would be really helpful.
“Not only that, but if it requires a prior auth, it would be nice if I could just put that information right into my EHR. It could be sent electronically, rather than filling out old-fashioned paper forms and logging into a proprietary system that just that insurance plan uses, so you have to have a second screen up on the computer and track how that goes separately. It just doesn’t feel like we are using 21st century technology here to solve this important problem.
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